Learning Objectives

After reading this article, you should be able to:

1. Understand the principles of motivational interviewing (MI) and its application in substance use disorder treatment.

2. Identify various types of change-talk and develop skills in responding effectively to the client.

3. Summarize some of the current research findings on psychiatric treatment.

CPTR: What is motivational interviewing (MI) and how did you discover it as a method of working with people with substance use disorder. 

Dr. Miller: It is a counseling style to help strengthen a person’s own motivation for and commitment to change. It works from the client’s strengths. Instead of saying, “I have what you need, and I’m going to give it to you,” in MI our message to the client is: “You have what you need, and together we will find it.” I wouldn’t say that I “discovered” it as much as “noticed” it in how I was responding to clients, and how they responded to me. Many people have made similar observations.

CPTR: How is motivational interviewing different than other counseling, say supportive therapy?

Dr. Miller: MI stands on the shoulders of Carl Rogers, and I think of it as an evolution of his client-centered approach. There is a clear direction to MI—the counselor consciously and strategically moves toward a particular goal, so it’s directional, but not “directive” in the usual sense of that term. Typically, it is the client who sets the goal. Sometimes it is determined by the context. Someone who walks through the door of a smoking cessation clinic doesn’t wonder what the subject of conversation will be. Most 20th century treatment methods in the addiction field were highly directive, even authoritarian, and MI is certainly quite different from that kind of expert role. MI is a meeting of expertise—our own, and the clients’ substantial expertise about themselves.

CPTR: Does motivational interviewing work equally as well when it comes to treating all substances that people abuse?

Dr. Miller: The evidence base for MI is strong with alcohol, tobacco, and marijuana, and there are positive trials with stimulants and opioids as well (Calomarde-Gómez, C., Jiménez-Fernández, B., Balcells-Oliveró, M., Gual, A., & López-Pelayo, H. (2021). Motivational Interviewing for Cannabis Use Disorders: A Systematic Review and Meta-Analysis. European addiction research, 27(6), 413–427. https://doi.org/10.1159/000515667). Particularly with the latter, MI is not the sole component of treatment. It can be combined with cognitive behavior therapy, with 12-step facilitation, with medication. We never meant MI to be a comprehensive psychotherapy in itself. It is one component of treatment (DiClemente, C. C., Corno, C. M., Graydon, M. M., Wiprovnick, A. E., & Knoblach, D. J. (2017). Motivational interviewing, enhancement, and brief interventions over the last decade: A review of reviews of efficacy and effectiveness. Psychology of addictive behaviors: journal of the Society of Psychologists in Addictive Behaviors, 31(8), 862–887. https://doi.org/10.1037/adb0000318). It particularly contains key elements of therapeutic relationship—what makes some therapists more effective than others—and in that way it is a clinical style for doing what else you do whether it’s behavior therapy, psychoeducation, or medication management.

CPTR: Have there been new developments in the past few years in motivational interviewing?

Dr. Miller: Oh yes. There are now more than 2000 controlled clinical trials of MI across a broad range of cultures, and topics, and we know much more about how MI works. There is a lot of variability in the observed efficacy of MI across therapists, programs, and studies. About one-quarter of controlled trials have found no significant effect of MI, including one that we published from our own clinic (Miller WR et al, J Consult Clin Psych 2003;71:754–763). The heart of MI remains the same, but we know much more now about how to practice it well and how to help people learn it. The evidence base is strongest with substance use disorders because that’s where the most studies have been done, but there is a broad and rapidly growing literature on MI in medical settings across a broad range of health behaviors (Bischof, G., Bischof, A., & Rumpf, H. J. (2021). Motivational Interviewing: An Evidence-Based Approach for Use in Medical Practice. Deutsches Arzteblatt international, 118(7), 109–115. https://doi.org/10.3238/arztebl.m2021.0014). It’s also being applied in corrections, social work, coaching, leadership and education—fields where the research is newer.

CPTR: Does motivational interviewing come easier for some therapists? Or does it usually require the same intensive training for all?

Dr. Miller: Some people definitely learn it faster. If you’re already skillful in accurate empathy, that’s a big head start. Basic reflective listening is not an easy skill in itself. Once that is in place, MI is much easier to learn. A few people come to workshops and just seem to “get it.” They can demonstrate MI rather well based on their workshop training, but that is a small minority. Most people who come to a two-day workshop are not significantly more skillful with MI afterward. As with any complex skill, like playing a sport or a musical instrument, it helps to have some feedback and coaching over time. So far, we have found no relationship between years of education and the ability to learn MI.

CPTR: How does one become better at motivational interviewing?

Dr. Miller: An introductory workshop is a good start. We have shown that a workshop gives people a temporary boost that doesn’t happen with just reading or watching videos on your own. But learning MI is not an event, it’s a process. We’re not necessarily talking about a long process. In a randomized trial of methods for learning MI, we found that six coaching phone calls and feedback from a few observed practice over the course of four months made a substantial difference in competence (Miller, W. R., Yahne, C. E., Moyers, T. B., Martinez, J., & Pirritano, M. (2004). A randomized trial of methods to help clinicians learn motivational interviewing. Journal of consulting and clinical psychology, 72(6), 1050–1062. https://doi.org/10.1037/0022-006X.72.6.1050).

CPTR: Does motivational interviewing work with all ages, cultures, and psychiatric comorbidities?

Dr. Miller: With teenagers, we got some of the biggest effects we had ever observed. For people with schizophrenia, there are some nice effects on medication adherence and lowered rehospitalization. Chuck Bombardier has done great work with people with brain injury. It seems to cross cultures well. I’m aware of at least 61 languages in which MI is being taught and practiced. One area that’s not clear yet is MI’s effectiveness with younger children. There may be a level of cognitive development that’s needed for MI to trigger self-regulation. We know it works well with adolescents over 16 or so. It’s less clear with younger children, but with younger kids you really need to be talking to the parents anyhow.

CPTR: How do you get a patient into “change-talk” when that patient may not really want to change? How do you get them started?

Dr. Miller: That’s at the heart of MI. We have a broad range of different strategies for evoking change talk. Motivation is much broader than wanting to change. People certainly decide to make changes even though they don’t really want to; for example, because it is the right thing to do, or there are strong reasons to do it. MI is not a way of tricking people into doing what they don’t want to do. Motivation comes from within the person; it’s not “installed” but is already there. MI is about helping people talk themselves into change. I guess the most common method is to ask an open question, the answer to which is change-talk, and then follow with reflective listening to elaborate it. That sounds easy, but it’s quite an artful process, and like reflective listening, it can be done badly. We say that MI is simple, but not easy.

CPTR: What do you do when you go through this process and you determine that your patient is not motivated to make significant change?

Dr. Miller: That has to be OK with the practitioner. You need a certain amount of detachment, knowing in your heart that each person gets to make their own choices. We can’t take that autonomy away from people, although sometimes we wish we could, or even imagine that we can. “You can’t let alcoholics decide,” people used to say. The truth is that you cannot take away the ability to choose what one will think, or do, or be. But you ought to explore very carefully before deciding that there is insufficient motivation there. For so long we dismissed, even discharged people as “unmotivated.” Now we know that strengthening motivation for change is an important part of our job. Sometimes that’s all you need to do, and people take it from there.

CPTR: When patients start talking themselves into change, moving in the direction of change, is your work done?

Dr. Miller: Not necessarily. Rarely is it like flipping a switch. While it’s easy to overestimate how much help clients need from us, there certainly are people who choose and want and need to move into change, but they need help in doing so. “What is a next step?” is a good question to ask people once they seem to be moving toward change. The therapist doesn’t take over at that moment. We don’t say, “Now that we’ve got that motivation thing out of the way, let me tell you what to do.” What help, if any, does the person want? MI can be used throughout the change process and not just in getting ready for change. Getting “motivated” is also not usually a one-time event. It, too, is a process over time.

CPTR: What would be the more subtle examples of change-talk that we should be listening to that we might not necessarily easily catch?

Dr. Miller: That’s a challenge in learning MI, tuning your ears to hear change-talk of all kinds. We listen to tapes and grieve over all the change-talk that is right there but seems to be missed. Of all the things that clients tell you, these are the things that you really need to hear and respond well to, because they move in the direction of change (Kahler, C. W., Janssen, T., Gruber, S., Howe, C. J., Laws, M. B., Walthers, J., Magill, M., Mastroleo, N. R., & Monti, P. M. (2022). Change talk subtypes as predictors of alcohol use following brief motivational intervention. Psychology of addictive behaviors: journal of the Society of Psychologists in Addictive Behaviors, 10.1037/adb0000898. Advance online publication. https://doi.org/10.1037/adb0000898). Here’s an example. There is something we call “envisioning,” which is language that tells you the person is thinking about change, looking ahead, and imagining what it would be like.

That can sound like sustain-talk. “Well, I don’t know what I’d do for friends if I quit drinking.” It sounds like an argument against change, and if you don’t handle it well it can become that, but what’s really going on is that the person is already imagining having to quit drinking, and thinking what that would be like. Often that raises concerns. There can also be a tendency to discount low-intensity change talk. “Well, I guess I ought to quit drinking.” “I’ll think about it.” “Maybe I’ll try.” The qualifiers—maybe, think about it, I guess—can worry a counselor. “What do you mean, you’ll think about it? Are you going to do it or not?” Or therapists miss small steps in the right direction. “I had two days this week without drinking.” How should you respond? The practitioner’s “fixing reflex” pushes for exclaiming, “What? You mean that you drank on five days this week!?” But it’s a step in the right direction, and you should get interested and curious about it and say, “Really! How did you manage that? Tell me what you did.” Change often happens in smaller increments. We talk ourselves into change gradually. From that perspective, it’s amazing how quickly MI works sometimes.

CPTR: Thank you for your time, Dr. Miller.